Provider Demographics
NPI:1437546538
Name:COMMERCE SPINAL CENTER, PC
Entity Type:Organization
Organization Name:COMMERCE SPINAL CENTER, PC
Other - Org Name:BRASELTON CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEDRA
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:DAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-238-3456
Mailing Address - Street 1:6323 GRAND HICKORY DR
Mailing Address - Street 2:SUITE 300B
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-6272
Mailing Address - Country:US
Mailing Address - Phone:470-238-3456
Mailing Address - Fax:470-238-3455
Practice Address - Street 1:6323 GRAND HICKORY DR
Practice Address - Street 2:SUITE 300B
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-6272
Practice Address - Country:US
Practice Address - Phone:470-238-3456
Practice Address - Fax:470-238-3455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA08649111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2021350103Medicare PIN